Urolithiasis in patients with spinal cord injuries: risk factors,
management, and outcomes
Michael C. Ost and Benjamin R. Lee
Purpose of review
Despite major advances in the urological care of spinal
cord injury patients, the incidence of urolithiasis has not
changed. Although the incidence of kidneys lost to
staghorn calculus disease has decreased considerably,
stone disease is still a significant cause of morbidity and
concern. The purpose of this review is to summarize the
risk factors for the development of stone diseases in the
spinal cord injury patient population and present the
outcomes of current endourologic treatment modalities.
Recent findings
Recurrent urinary tract infections, indwelling catheters,
vesicoureteral reflux, and immobilization hypercalcuria are
a few of the major risk factors for the development of
urolithiasis among spinal cord injury patients. Retrograde
endourologic techniques are often not possible to address
stone disease due to lower extremity contractures, spinal
curvature, and pelvic tilt. Extracorporeal shockwave
lithotripsy success rates vary from 50 to 90%, but
clearance rates are often delayed. Success rates for
percutaneous nephrolithotomy match those quoted in the
general population ( > 90%), but at the expense of a
higher rate of complications (6–20%). Meticulous
planning with regard to appropriate prophylactic
antibiotics and body position will maximize efficacious
outcomes.
Summary
Early identification and treatment of urolithiasis in spinal
cord injury patients will aid in preserving renal function and
minimizing associated complications. Despite variation in
common urological practices between spinal cord injury
units and the lack of clear cut guidelines for follow-up, the
increased incidence of risks associated with urolithiasis
lends support for routine genitourinary imaging in order to
identify and treat those individuals at highest risk.
Keywords
bladder calculi, extracorporeal shockwave lithotripsy,
nephrolithiasis, percutaneous nephrolithotomy, spinal cord
injury
Curr Opin Urol 16:93–99. # 2006 Lippincott Williams & Wilkins.
Department of Urology, North Shore-Long Island Jewish Medical Center New
Hyde Park, New York, USA
Correspondence to Benjamin R. Lee MD, Associate Professor of Urology,
Department of Urology, Long Island Jewish Medical Center, New Hyde Park, NY
11040, USA
Tel: 718-470-7066, fax: 718-343-6254; e-mail: blee@lij.edu
Current Opinion in Urology 2006, 16:93–99
Abbreviations
ESWL extracorporeal shockwave lithotripsy
PCNL percutaneous nephrolithotomy
SCI spinal cord injury
# 2006 Lippincott Williams & Wilkins
0963-0643
Introduction
Altered afferent pathways and contracted extremities
can often make the clinical diagnosis and treatment of
urolithiasis challenging in spinal cord injury (SCI)
patients. Identifying the risk factors for the develop-
ment of urolithiasis and focusing on preoperative plan-
ning can help maximize treatment efficacy and mini-
mize recurrences.
Epidemiology and risk factors for urolithiasis
in the spinal cord injury population
Patients with SCIs are more prone to develop chronic
and complicated stone disease over their lifetime.
Within 10 years following a SCI, 7% will develop an
initial kidney stone, with the greatest risk occurring dur-
ing the first 3 months following the injury [1]. Despite
the major improvements in the urologic care of SCI
patients over the last 25 years, the incidence of stone
formation in this patient population, to much surprise,
has not changed. In this patient cohort, unrecognized
stone disease can contribute to renal failure, a significant
source of morbidity and mortality. Upper and lower
urinary tract stasis, vesicoureteral reflux, detrusor-
sphincter dysfunction, and chronic catheterization are
just a few factors that can contribute to the development
of urinary tract infections with resultant stone formation.
Indeed, 98% of urolithiasis in the SCI population is
either apatite (calcium phosphate) or struvite (magne-
sium ammonium phosphate) in composition [2]. With
this in mind, recurrent urinary tract infections and septic
episodes should alert the consulting urologist to the high
probability of stone disease in the SCI patient.
Two major risk periods may exist for stone formation in
the SCI patient. During the acute phase following SCI
when immobilization is most prevalent, there is evi-
dence of ‘immobilization hypercalcuria’ contributing to
non-oxalate calcium stone formation [3]. Thereafter,
stone formation is most often the result of infected
urine. Infection may be secondary incomplete emptying
93
94 Urolithiasis
with urinary stasis, repeated instrumentation or catheter-
izations, and foreign bodies (i.e. hair introduced during
clean intermittent catheterization). Other unique meta-
bolic disturbances in the spinal cord population may
contribute to stone formation. In an analysis excluding
SCI patients with urea splitting urinary tract infections,
Burr et al. [4] demonstrated that SCI patients can be
alkalotic with concomitant hypocituria when compared
to control subjects. A model for the formation of calculi
in SCI patients was later described by Burr and
Nuseibeh [5] in which indwelling urinary catheter
encrustation was dependent on urinary pH, calcium,
and flow rate.
It has long been a subject of debate whether the level of
SCI is a risk factor for upper-tract stone formation. An
early investigation reported that SCI patients with com-
plete lesions at level T4 or higher had a higher inci-
dence of nephrolithiasis than those with incomplete
lesions above T4 or any types of lesions below T4 [6].
In contrast, a later study demonstrated that complete-
ness of the cord lesion was an insignificant factor in pre-
dicting the formation of stone disease [7]. Levy and
Resnick [8] have astutely pointed out that data from
well documented studies such as these are contradictory
and inconclusive because of the many confounding vari-
ables contributing to stone disease that have not been
controlled for. The presence of infection, time from
injury, and catheter status must be taken into account
in order to determine whether a neurologically complete
lesion in and of itself is truly a risk factor for stone for-
mation. What is more conclusive in the SCI population,
however, is the increased risk of renal stone formation
when there is vesicoureteral reflux, bladder stones,
and/or the presence of an indwelling foley catheter
[9,10]. Along these lines, an older SCI patient with a
complete lesion and an indwelling foley catheter is at
an increased risk of developing a bladder stone [11•]
In a recent evaluation of the national SCI database, it
was determined that, similar to the general population,
geographic variation and environmental risk factors may
contribute to the formation of an initial kidney stone in
the SCI population [12]. Specifically, the incidence of
stone formation was significantly greater in the South-
east United States, tending to increase with decreasing
latitude. These findings suggest that stone-formation
risk in SCI patients may be decreased by modifying
environmental exposure.
The extraordinarily increased risk of a SCI patient
developing urolithiasis coupled with the atypical presen-
tation of renal colic (altered upper-tract afferent path-
ways) strengthens the argument to routinely screen the
urinary tract with imaging (i.e. annual sonogram of
kidney/bladder). Early detection and aggressive treat-
ment of urolithiasis in the SCI patient will avert the
potential for renal damage or loss. Although modern
endourological equipment and technique has facilitated
easier and efficacious treatments of urolithiasis, it is not
surprising that management of stone disease in this spe-
cial patient population focuses equally on prevention.
Preoperative considerations in the spinal
cord injury patient
The urinary tracts of SCI patients are most often colo-
nized due to chronic catheter use. In light of this, inju-
dicious use of antibiotics may more readily result in the
development of multidrug resistant organisms [13].
Along these lines, it is imperative that the results of a
urine culture with sensitivities are known at least 7 days
prior to stone treatment. During this pre-procedure time
period, appropriate prophylactic antibiotic therapy
should be started in order to minimize the chances of
urosepsis during urinary tract manipulation and stone
fragmentation. Re-culturing the urine and obtaining
sensitivities immediately following the procedure may
also be of prophylactic benefit. Bacteria released from
fragmented stones may differ from the pre-operative
colonized urinary tract flora. In the event that urosepsis
develops postoperatively, results of the immediate post-
operative cultures may help to guide antibiotic therapy
until a third set of urine cultures, taken at the time of
the septic event, are available.
Perhaps most crucial to preoperative planning is an
assessment of extremity and trunk mobility. Depending
on the level and duration of the SCI, various degrees of
extremity contracture, spinal curvature, or pelvic tilt will
exist. In addition, prior placement of spinal hardware
may alter the ability to suitably position SCI patients
for routine stone management. Performing endourologi-
cal procedures in the dorsal lithotomy position (i.e. ure-
teroscopy) and properly positioning patients on some
extracorporeal shockwave lithotripsy (ESWL) gantries
(i.e. Dornier HM3), for example, may be extraordinarily
difficult. Adding external spreader bars to a cystoscopy
table may aid in achieving a split-leg position in these
patients whether it be prone or supine. Furthermore,
newer generation mobile ESWL machines allow for
more flexibility with patient positioning.
Nephrolithiais of the upper tract:
extracorporeal shockwave lithotripsy
and percutaneous nephrolithotomy
ESWL and percutaneous nephrolithotomy (PCNL) are
the most frequently used endourological modalities to
address stone disease of the upper tracts in SCI patients.
Lower extremity contractures often limit the use of ret-
rograde ureteroscopy in the treatment of ureteral stones.

Extracorporeal shockwave lithotripsy
Almost all stones that form in a SCI patient will be soft
and radio-opaque. Bearing this in mind, ESWL can be
considered a first-line treatment for smaller (< 1.5 cm)
upper-tract stones provided there are no medical contra-
indications. Although staghorn calculi can be treated by
ESWL, multiple treatments are often required with poor
clearance rates. ESWL monotherapy for a staghorn cal-
culus should be reserved for those patients that are poor
candidates for PCNL. In this particular subset of SCI
stone patients, chemolysis through a nephrostomy tube
with hemiacidrin or Suby’s Solution G can serve as an
adjunct to ESWL sessions. When utilizing chemolysis,
care should be taken to maintain renal pelvic pressures
below 25 cmH2O, thus minimizing the risk of septi-
cemia from pyelovenous backflow.
Overall, ESWL is a safe modality for stone treatment in
SCI patients. Stone fragment clearance following treat-
ment, however, may be somewhat poorer than the gen-
eral population and is often delayed [14]. Quadriplegics
with high-level cord injuries requiring cardiac pace-
makers [15] and those with baclofen pumps [16] have
safely undergone ESWL without complications. ESWL
has been performed without general or regional anesthe-
sia without causing autonomic dysreflexia, although
hypertension during treatment has required intravenous
administration of hydralazine [17]. Standard anesthesia
monitoring is therefore required for all patients.
In the instances of severe spinal curvature or contrac-
tures, difficulties in accurately localizing renal calculi
should be anticipated. Care should be taken to maintain
the stone within the ESWL focal point and to spot
check the location frequently; renal atrophy following
multiple ESWL sessions for a staghorn calculus has
been reported in a paraplegic patient with marked spinal
curvature in which stone localization was suboptimal
[18].
Despite the widespread use of ESWL in the SCI popu-
lation, there are few modern published series in the lit-
erature. The earliest report showed a poor overall stone-
free rate of approximately 50% [19]. Soon after, Lazare et
al. [20] reported a 73% stone-free rate at 3 months in 32
SCI patients treated with the Dornier HM3 lithotripter.
In this cohort of patients, average stone size was 2.9 cm
and treatment did not alter serum creatinine values.
Similarly, Deliveliotis et al. [21] reported an approximate
66% (10/15 patients) stone-free rate at 6–20 months after
treatment; those patients with residual fragments (5/15)
had either staghorn calculi or fragments greater than
2.5 cm in diameter.
Urolithiasis and spinal cord injuries Ost and Lee 95
Ureteroscopy
To date there are no published studies reporting solely
on the outcomes for ureteroscopic management of stone
disease in SCI patients. When utilized, flexible uretero-
scopy is most often required owing to the difficulties
associated with retrograde instrumentation in the dorsal
lithotomy position. Antegrade flexible ureteroscopy, fol-
lowing percutaneous renal access and tract dilation, is
our preferred method of treating ureteral stones in SCI
patients without urinary diversions. We find that this
approach bypasses the limitations incurred by extremity
and trunk contractures (Fig. 1).
Percutaneous nephrolithotomy
PCNL is the treatment of choice for calculi greater
than 1.5 cm located in the renal pelvis or any calyx.
Our method of access, tract dilation, and stone extrac-
tion does not differ from the general population and may
readily be employed in SCI patients [22]. Indeed,
PCNL has been performed successfully in ectopic
pelvic kidneys in patients with sacral agenesis with
severe bilateral lower extremity contractures, atrophic
lower extremities, and spinal curvature [23].
Culkin et al. [24] published a 90.4% stone-free rate fol-
lowing PCNL, based on nephrostograms and tomo-
grams, in SCI patients who underwent an average of
2.04 procedures for struvite stones. Of note in this
early study was an 8.5% major complication rate due to
respiratory arrest, perirenal abscesses, and hydrothorax.
In a later comparative study, the same authors reported
an even higher complication rate (20%) among their SCI
Figure 1 A T6 partial paraplegic patient with atrophic and
contracted lower extremities prior to positioning for
percutaneous access to perform antegrade ureteroscopy and
laser lithotripsy for a 1 cm mid-ureteral stone
Management with a rigid ureteroscope in the dorsal lithotomy position
would not have been possible
96 Urolithiasis

patients, who had an 88.6% stone-free rate compared Figure 2 An incomplete C3 quadriplegic patient with a left
with a 98.5% success rate in an ambulatory group [25]. staghorn calculus and sizeable stone within the ileal conduit
The only recent report on PCNL in SCI patients has
been published by Lawrentschuk et al. [26••], in which
a 28F single-stage renal and fascial dilator (‘webb’ dila-
tor, William A. Cook Australia Pty Ltd, Brisbane, Aus-
tralia) was used to obtain access. In this study, the com-
plete stone-free rate was 87% for PCNL monotherapy,
increasing to 92% with adjuvant treatments.

Rubenstein et al. [27•] retrospectively reviewed their

experience performing PCNL on 23 patients with neu-
rogenic bladder dysfunction, nine of which had a urinary
diversion. Individuals with spina bifida, traumatic SCI,
extrophy/epispadias, neonatal meningitis, stroke, and
spinal chondrosarcoma were included in the study.
Despite a 46% stone recurrence rate, the authors
reported a 96% stone-free rate with minimal complica-
tions occurring.

Percutaneous nephrolithotomy and urinary diversions

It is not uncommon for quadriplegics to have an ileal
conduit and for paraplegics with adequate hand function
to have a continent catheterizable urinary diversion.
The patient was treated by PCNL for the staghorn calculus (A).
A nephroscope and ultrasonic lithotripter were used (trans-stoma) to
Patients with staghorn calculi and urinary diversions are treat the stone within the ileal conduit (B).
approached like any complex branched renal stone –
percutaneously (Fig. 2). Success rates approach 90%
when second-look procedures are undertaken. Similarly,
ureteral stones are approached percutaneously because
demonstrated that intermittent catheterization clearly
access to the ureter is often much more straightforward
had an advantage over an indwelling foley catheter
than the retrograde approach. After through and through
with regard to the incidence of bladder stones (5% com-
access is obtained, the flexible urteroscope may be
pared with 22%) and renal calculi (4% compared with
passed either retrograde or antegrade to accomplish
8%) formation over a 3-year period [29].
Ho:YAG lasering or stone basketing.

Urinary calculi of the lower tract: bladder
stones and stones in diversions
Techniques to treat vesical calculi in the SCI population
do not differ much from the procedures used to treat
bladder stones in the general population. Addressing
stones that have formed in urinary diversions requires
advanced endourological skills.
Bladder stones
Overall improvement in SCI urologic care over the last
30 years has led to a decrease in bladder stone forma-
tion. Chen et al. [28] determined that from the period
1973–1979 to 1990–1996, for example, there was a sig-
nificant decrease in SCI vesical calculi from 29 to 8%.
Despite these statistics, the subset of SCI patients with
complete lesions limiting hand function, and thus the
ability to self-catheterize, will remain at higher risk for
bladder and renal stone development. An early study
from a Veterans Administration Hospital, for example,
Interestingly, in a recent sizeable multicenter longitudi-
nal study, the inability to control bladder function dur-
ing the first year after injury was an important risk factor
for stone formation; however, the type of urinary drain-
age used thereafter, including indwelling, intermittent,
or condom catheterization, had no significant differential
effect [1]. Regardless of this finding, it is accepted that
SCI patients released from the hospital with an indwel-
ling catheter are 6.1 times more likely to develop a blad-
der stone than individuals with normal lower urinary
tract function [30]. The type of indwelling catheter
used (suprapubic or urethral) will not significantly
change this risk [31].
Prior to treatment, etiologies of bladder outlet obstruc-
tion (benign prostatic hyperplasia, urethral strictures,
sphincter dysenergia) that contribute to vesical calculus
formation should be identified and factored into the
treatment plan. It should be kept in mind that a chronic

indwelling catheter, a history of smoking, and the pre-
sence of both renal and bladder stones are important risk
factors for the development of squamous cell carcinoma
and transitional cell carcinoma of the bladder [32]. In
light of this, there should be a low threshold to biopsy
any suspicious bladder mucosal lesions associated with a
vesical calculus.
Depending on the surgeon’s preference, large bladder
stones (> 6 cm) or heavy stone burdens can be treated
percutaneously with an ultrasonic lithotripter (through
an Amplatz dilated 30F cytostomy tract) or by a tradi-
tional open cystolithotomy. In the instance of small
bladder capacity and/or poor compliance, percutaneous
treatment may be more challenging. Overall, treatment
of bladder stones in SCI patients should not differ from
vesical calculus treatment in the non-SCI population. A
detailed review on this subject is provided by Schwartz
and Stoller [33].
As in the general population, bladder calculi of small to
intermediate size (up to 4 cm) may be treated transur-
ethrally by electrohydraulic lithotripsy or Ho:YAG laser
lithotripsy. Kilciler et al. [34] describe treating such
bladder stones with ESWL at an average of 34 minutes
without anesthesia. Following treatment the bladder is
irrigated with a 20% providone iodine solution and frag-
ments are evacuated through a 22F sheath. Specifically,
20 paraplegics with a mean bladder stone size of 3 cm
were treated with a Siemens Lithostar Plus second-gen-
eration lithotripter (mean of 3600 shocks at a power of
19 kW s–1). Eighty percent (16/20) were stone free after
one session and 20% (4/20) required one additional
treatment. ESWL for bladder stones may be an ideal
treatment for SCI patients who are anesthetic risks or
prone to autonomic dysreflexia.
Stones in urinary diversions
Most stones formed in SCI patients with urinary-intest-
inal diversions are struvite, although metabolic distur-
bances contribute to overall stone composition. Foreign
materials, retained intestinal mucous, incomplete emp-
tying, chronic bacterial colonization of the reservoir, and
chronic metabolic acidosis with resultant hypocitraturia
all contribute to stone precipitation. The incidence of
stone formation varies by type of diversion. A trans-
stomal approach and percutaneous poucholithotomy are
two unique endourologic modalities for stone manage-
ment in this patient population.
The management of stones in the urinary diversions of
SCI patients is often difficult, requiring advanced
endourologic skill. Complexity results from the absence
of typical landmarks coupled with an altered body habi-
tus. Understanding the anatomy of the particular diver-
Urolithiasis and spinal cord injuries Ost and Lee 97
Figure 3 Percutaneous access for poucholithotomy in an
Indiana Pouch
sion will help determine which access is best suited for
the clinical scenario. Unique percutaneous approaches
should always be considered the first-line step in
approaching these stones in urinary diversions.
In SCI patients with continent cutaneous diversions/
nipple valves (i.e. Indiana Pouch) or catheterizable
stomas (i.e. Mitrofanoff valve), any endourological treat-
ment through the continence mechanism should be
avoided. The potential for damaging the continence
mechanism or inducing a stricture is high. When stone
burden is heavy, Amplatz sheaths and/or laparoscopic
trocars should be placed percutaneously in order to max-
imize visibility and treatment efficacy (Fig. 3). It is our
practice to deploy a laparoscopic entrapment sac as
described by Jarrett et al. [35] in order to maximize vis-
ibility and avoid imbedding stone fragments into friable
intestinal mucosa during ultrasonic lithotripsy. Details
on the medical work-up [36] and surgical management
[37••] of stones in patients with urinary diversions are
beyond the scope of this article and are offered else-
where.
Prevention, strategies to decrease risk,
and long-term follow-up
Minimizing the risk factors contributing to urinary tract
infections will decrease the formation of urolithiasis and
will minimize morbidity in SCI patients. Clean intermit-
tent catheterization is the most basic preventive mea-
sure and is highly recommended [38]. Prophylactic anti-
biotics should not be used as they significantly increase
the risk of multidrug resistant resistance. Indwelling
foley catheters should be avoided as they are prone to
encrustation and can contribute to the formation of
98 Urolithiasis
nephrolithiasis. If an indwelling foley catheter must be
used, weekly catheter changes can dramatically reduce
catheter encrustation and stone formation [39]. Although
it is controversial as to whether SCI patients should be
imaged on a regular interval, it is our belief that this
surveillance imaging is critical, especially in the instance
of SCI and stone disease. An annual sonogram at the
time of annual urodynamic studies may serve as a refer-
ence point to monitor stone formation.
To prevent the formation of urolithiasis, SCI patients
are often advised to increase fluid intake, a recommen-
dation applicable to the adult stone-forming population.
The observation that higher urine specific gravities
occur among SCI stone-forming patients [40] lends sup-
port to this recommendation as a means of prevention.
Chen et al. [41] performed an age-matched case–control
study to clarify the interrelation of fluid intake, beverage
type, and mineral content on the formation of urinary
stones among persons with SCI. Interestingly, in a mul-
tivariable model that adjusted for other possible risk fac-
tors, only greater juice consumption (> 207 cm3 per day)
was associated with a decreased risk of recurrent stone
formation (70%). Despite this report, further verification
studies are required before guidelines and recommenda-
tions regarding fluid intake are applicable to the SCI
stone-forming population.
In a recent case report, oral isodium etidronate therapy
(400 mg daily) was used to prevent recurrent calcium
phosphate stones in a patient with hypercalcuria in the
face of increased bone resorption [42]. Perhaps, in the
future, biphosphonate therapy may play a more integral
role in bladder-stone prevention in the SCI population
with significant hypercalcuria not corrected by tradi-
tional means.
Conclusions
The main objective in the urological management of
SCI patients is the prevention of upper-tract injury and
resultant renal failure by maintaining a sterile, unob-
structed, and low-pressure genitourinary system. The
presence of nephrolithisis is a common problem among
SCI patients, which must be addressed during routine
urological care in order to minimize the increased risk
of renal insufficiency [43]. ESWL and PCNL have
been demonstrated to be effective treatment modalities
despite delays in fragment clearance and a slightly
higher rate of complications. Despite remarkable varia-
tion in common urological practices between SCI units
and the lack of clear-cut guidelines for follow-up [44•],
the increased incidence of urolithiasis among SCI
patients with associated morbidities lends support for
routine genitourinary imaging in order to identify and
treat those individuals at highest risk.
References and recommended reading
Papers of particular interest, published within the annual period of review, have
been highlighted as:
• of special interest
•• of outstanding interest
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